When to have an ablation

People often ask on the forum when is a good time to have an ablation. This might help.

From Dr Jaïs, comment to a-fib.com on his remodelling presentation at the Boston Symposium:-

Dr. Jais, in an email to the author, added, “both experimental and human data strongly advocate early ablation in persistent A-Fib, while there is no emergency in paroxysmal A-Fib. Several ongoing studies should demonstrate that in the future.” He also wrote, “I do believe we will also see studies demonstrating the benefit of A-Fib ablation on morbidity and mortality.”

[a-fib.com]

Gill

What is the true definition of persistent AFIB ?
I get AFIB every 7-10 days usually converting within 24-48 hours. Been on daily dose of Flec 150mg am and 100mg Pm
Flec also prevents structural and electrical remodeling according to a Euuropace Study
My episodes are basically mild but I know it when I'm off
I guess this is reinforced by the Japanese study too!



Edited 2 time(s). Last edit at 03/25/2013 05:33PM by McHale.

McHale

My understanding is that persistent means that you can be cardioverted back to sinus rhythm. Permanent means that cardioversion does not work.

Gill

Gill,
My episodes never lasted more than a week.
But I do use Flecainide so does that change my classification? I'd rather stay on Flec than stop and try to find out if my frequency changes.

TYPES OF A-FIB

There are three types of Atrial Fibrillation. In casual usage you may hear the three types of A Fib described as occasional, persistent, and permanent or chronic A Fib. Your doctor, however, may use one of the following medical terms:

Paroxysmal: (pronounced par-ok-SIZ-mal) describes episodes that stop on their own, and last anywhere from seconds or minutes, to hours or up to a week
Persistent: episodes which last more than a week; or episodes lasting less than a week but only stopped by cardioversion
Long-standing Persistent: a type of Persistent A Fib that lasts longer than one year; (formerly called Chronic or Permanent)

Note: the terms Paroxysmal and Persistent are not mutually exclusive. You may have several episodes of paroxysmal A Fib and occasional persistent A Fib, or the reverse. Your A Fib is called by whichever occurs most often.

Hi McHale,

Technically Persistent AFIB episodes are not amenable to chemical cardioversion and need to have lasted at least a week duration without either a spontaneous conversion back to NSR or a ECV conversion to NSR.

Then, with all future triggers back into AFIB it will require another Electrocardioversion to get back to NSR and drugs will only help control the rate, at best, in the vast majority of true persistent AFIB cases.

When ECV cardioversions no longer work and you have unbroken 24/7 AFIB for a full year's duration, that is considered 'permanent AFIB', but in reality a full year's time is rather arbitrary once the ECVs stop converting one to NSR.

In your case McHale, as you describe it above, it is still paroxysmal AFIB that stops on its own but with episodes lasting as long as 24 to 48 hours. That is considered long standing complex paroxysmal AFIB and in the vast majority of cases will require additional ablation work in addition to, and outside of, a standard PVI isolation addressing other anatomical areas of the left and sometimes right atrium as well as focal trigger spots located with real time mapping during the ablation in order to have much chance for good success. And, as with persistent AFIB, these more long lasting paroxysmal cases often require a second 'touch up' ablation .. or even three at times ... to achieve a very long to indefinite period of NSR.

There is a significant difference between the relatively simple and widely-spaced paroxysmal episodes that last well under 12 hours, or even much shorter in the 2 hour to 6 hour range, and the more progressive stages of paroxysmal AFIB with their 24+ hour duration and increasing overall frequency of occurance.

This reality underlies the old adage that 'AFIB begets more AFIB' regardless of what someone's interpretation to the contrary of one of the fibrosis discussions at BAF might imply.

Shannon



Edited 1 time(s). Last edit at 03/26/2013 03:46PM by Shannon.

" it is still paroxysmal AFIB that stops on its own but with episodes lasting as long as 24 to 48 hours. That is considered long standing complex paroxysmal AFIB and in the vast majority of cases will require additional ablation work in addition to, and outside of a standard PVI isolation"

Shannon, are there to your knowledge any studies detailing how many of these 24 hr episodes have to occur to be regarded as long standing? Or an indication as their frequency in relation to shorter episodes?

Hi afhound99,

In my experience, the most skilled ablationists I have seen, for example both Drs Natale and Haissaguerre, each asked what my longest episode was during our first meetings (this was when I first saw them prior to slipping into 24/7 persistent AFIB some 5 months later while I was still procrastinating on when to get an ablation). They both indicated that for the vast majority of longer duration (24+ hours paroxysmal episodes) and almost invariably with full on persistent AFIB that the procedure would have to expand beyond the standard PVI only protocol to include other non-PV anatomical areas and possibly addition real time 'CAFE' focal trigger spots in the rest of the left atrium and also right atrium in some cases.

My understanding for this to be true was even one 24 hour or longer episode was the threshold for the EP having to venture beyond the PVs alone to give you the best chance for longer term success.

Shannon

PS Afhound99,

When the heart can sustain AFIB for 24 hours or longer that is a strong indication that remodeling has expanded to include more complex triggering most often including not only the PVs which need to be isolated in all accepted current ablation protocols, but also beyond the PVs in the other areas of the left and right atriums mentioned.

Shannon

Ok thanks Shannon. I asked because I had had 1 or 2 episodes that lasted 24-30 hrs and I asked the EP if there was any remodelling likely (and he had the MRI as well as the echo at that point, whatever they could tell him) and he said no there wasn't likely any.

I was paroxysmal for many years (about 10) with ranges from a few minutes up to 3 days. One day I went persistent which lasted 3 months...until I was ablated. My EP had no issue with sustaining afib vs cardioversion (also has risks, BTW). As of now, about 6 months out, I have not had a second ablation and have had no afib, although I have had a few very short runs of tachy. I asked the EP post-ablation if he had burned areas outside the PVI isolation and he said no - no secondary areas found. The doc is very experienced - over 1200 ablations. Even though I was persistent, prior to the ablation he stated my chance of ablation success was only about 5 to 10 percent less than a paroxysmal patient - and after the ablation he stated my chances of success were the same as a paroxysmal patient - about 67 percent.

The stats may be misleading regarding the need for second or third ablations if one is persistent - as many patients go right back to alchohol and other stimulants during the blanking period - never giving the heart tissues a chance to heal properly. I bet if the stats were based on people who made sure their diet was optimal for ion replacment, and took care to avoid triggers (stimulants) the comparative outcomes would be much better.

Tom

Tom - Good last paragraph observation.

I have talked to numerous ablatees who had post-ablation problems but who had also not done any of the nutritional repletions prior to or else had stopped after ablation. One person in particular ate out (restaurant) 3 meals a day. He had no nutritional counselling prior to the ablation and was totally unaware of the problem with the Na/K ratio imbalance. Didn't know about magnesium. After about 4 months, and after considerable adjustments, his heart calmed down and I think he'd say his single ablation was a success at this point a few years later.

Jackie